Tackling childhood obesity - part 1

Webinar summary

18 July 2018

General practitioners are in a key position to provide support, advocacy and coordinate management for children above a healthy weight. This is the first of a four part series for managing childhood obesity, this webinar review’s current prevalence data with the goal to help you better understand childhood obesity in different cultural and socioeconomic contexts, and discuss how socioeconomic factors can contribute to health inequalities for children. We go over how to accurately assess a child’s weight status using appropriate BMI for age charts and lead discussions on how to discuss a child’s growth with families in a culturally sensitive way whilst also taking into account the challenges of social disadvantage, which may include poor health literacy, limited English or and economic hardship.

Presenters

Dr Natalie Cochrane

Dr Jessica Watson

Sammi: Good evening everybody and welcome to this evening’s twilight online Tackling Childhood Obesity (Part 1) webinar. My name is Samantha and I am your host for this evening. Before we make a start, I would like to just make a quick Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work and we pay our respects to Elders past and present. So I would like to introduce our presenters for this evening. We are joined by our presenter, Dr Natalie Cochrane and our facilitator, Dr Jessica Watson. Natalie is a GP at Mount Druitt Medical Centre in Western Sydney where she has worked for the last four years since completing her Fellowship. Natalie has a strong interest in child health and preventative care and most recently has been a member of ACI’s diabetes taskforce. And Jessica is a GP in the Nepean Blue Mountains and a team doctor for the Australian Dolphins Swim Team. So, welcome Natalie and Jessica. Thank you for joining us tonight.

Natalie: Thank you.

Jessica: Thank you.

Sammi: Alrighty. I will hand over to our facilitator Jessica now to take us through the learning outcomes for this evening and then we will get on with the presentation.

Jessica: Good evening everyone. Just to start off we will go through and highlight the learning outcomes. By the end of this online QI and CPD activity, you should be able to, utilise current prevalence data, so understand childhood obesity in different cultural and socioeconomic contexts, identify how socioeconomic factors can contribute to health inequalities for children above a healthy weight, assess a child’s weight status as part of a routine growth assessment. Some of you might have software that already does that, but if you do not, we will go through that later on in the talk. Discuss children’s growth and provide advice for families in a culturally sensitive way while taking into account the context of social disadvantage. And I will let Natalie go through the New South Wales Premier’s Priority.

Natalie: Yes. So in Australia, there are many initiatives to address childhood overweight and obesity rates and we will link to state-specific resources at the end of this presentation. Improving childhood overweight and obesity rates is one of the key Premier’s Priorities. It has been identified as a priority due to its links to psychological, social and health problems. Just to give an overview, the Premier’s Priorities started in 2015 with the aim to reduce the rates of childhood overweight and obesity by 5 percentage points by 2025. This involves a multifaceted approach as can be seen on this slide, and we are approaching the problem, this problem from many angles as it is a very complex problem. There are a range of programs influencing childhood settings like school and day care, social marketing campaigns and projects to change the physical environment to better promote physical activity and access to healthier food choices. The top left box on this slide shows a particular push to embed prevention and management of childhood obesity as part of routine clinical care. From now, all New South Wales health facilities are working towards the measurement of height and weight of all children and to provide families with advice and referrals where appropriate, such as to programs like Go 4 Fun and Get Healthy. Part of this work also involves referral to treatment programs and will also involve referrals back to GPs.

So, what is the role for GPs? General practitioners play a crucial role. We know that GPs are one of the most trusted sources of information for parents. GPs are commonly the first and sometimes only point of contact children may have with the health system. For example, at routine childhood vaccination visits. GPs often treat the whole family, so they know the child in their family and social context and can provide continuity and care coordination. GPs are very experienced in managing many chronic illnesses, for example diabetes, and GPs are in a position to assess and treat the health of a whole population due to the large volume of patients that they see. And GPs are starting to see their role in population health management more and more. GPs have an established role in preventative health activities as well as knowledge with the RACGP Red book, and good preventative care is very important as what happens in a child’s first few years of life will have a profound effect on their health as adults.

So just so we are all understanding, these are the weight status definitions that we will be using throughout the talk. This language has been extensively tested with children and their families. It is found to be easily understandable, conveying a positive message and using a non-judgemental approach. The first definition is “below a healthy weight” which is less than the 5th percentile. A “healthy weight” is the 5th to the 85th percentile. “Above a healthy weight” is the 85th percentile to less than the 95th percentile, and “well above a healthy weight” is the 95th percentile and above. It is important to note that this language is used and these definitions are used as a screening tool and a guide to the risk of health of the child, not as a label or a diagnosis, but is to assist in seeking improvements in the health of the child and adolescent, i.e. aiming to improve both their psychological and physical health and make them as happy and healthy as possible.

Jessica: Childhood obesity rates have plateaued, however increasing disproportionately among disadvantaged groups, including culturally and linguistically diverse communities and those from lower and middle socioeconomic backgrounds. Last year, the 2015 New South Wales school physical activity and nutrition survey data was released. Before we look closely at some data, I have a quick snap shot to help understand the prevalence differences for children from different backgrounds. What of school-aged children were overweight or obese?

Natalie: So one in four children, about 24.5% of children and adolescents were found to be overweight or obese, with 7% of these children in the obese category.

Jessica: Children of Middle Eastern background.

Natalie: Compared to the general population, children with Middle Eastern background were found to have a prevalence of about 42.3%.

Jessica: How does prevalence compare in different socioeconomic groups?

Natalie: Comparing the highest and lowest socioeconomic groups, the highest socioeconomic status group was found to have a prevalence of only 19.3% compared to the lowest quintile which had a percentage of about 33.7%.

Jessica: And for the Aboriginal and Torres Strait Islander children?

Natalie: The rates of childhood overweight and obesity amongst Aboriginal and Torres Strait Islander children is around 30%.

So we have all heard of the social determinants of health, where health and wellbeing of children is influenced by social determinants such as their family circumstances, school, community and the built environment. And we know that there are many forms of disadvantage and often individuals and families are impacted by more than one of these. For example, socioeconomic status we can see that the lowest quintiles are characterised by factors such as lower employment and income levels, lower levels of education, geographical challenges such as difficulty in accessing good quality healthy food. You may have heard of the concept of food deserts where there is little availability of good quality fresh food and a high proportion of fast food and take away outlets in an area. We know that from some data, that this is higher, these are much higher in areas of lower socioeconomic status and worryingly, they are also higher around schools in areas of lower socioeconomic status. Things like availability of safe community places for children to play is also a factor. If you are from a rural or a remote area, you might find that there are changes for preventative health program delivery that effects your access to health services, access to affordable healthy food and reliance on private car use and private transport and less active modes of transport. Health literacy, language and culture also have a vital role to play. It is more than just being able to read and understand a pamphlet or make an appointment, but it really looks at a person’s ability to understand information and use it effectively to improve their health and apply it in their life. We need to make sure resources are available in patient’s own language and is also culturally appropriate.

Sammi: And Natalie, we just had a question come through as well, that those percentiles we went through at the beginning, just clarifying that they are based on the BMI for age. Is that correct?

Natalie: Yes, that is correct. They are based on the BMI for age charts.

Sammi: Perfect.

Natalie: Okay, so the next slide is looking at a graph that displays the proportion of overweight and obese children aged two to seven, divided up by age group and gender. It is important to have a look at this data, as we know that overweight and obesity is a major public health issue, second only to tobacco smoking as a risk factor contributing to the burden of disease in Australia. We know that overweight children are significantly more likely to become overweight or obese as adults. This graph gives us a breakdown of overweight and obesity for boys and girls by age. We are just going to have a look at this as a population view first, before we start looking more closely at our different priority groups. We can see here that the rates are steadily increasing across all age groups and boys have a higher prevalence than girls, especially in adolescent boys. I think the key thing to note is that early intervention is critical. Children aged 2-4 years are experiencing obesity already and as we will see later when we start discussing the data from the SPANS report, we find that parents are often very unaware of this problem. Prevalence is also higher in these age groups for boys versus girls and also as children become adolescents, the rates of obesity versus overweight starts to significantly increase, highlighting the importance of identifying these children with routine growth assessments so that we can provide the appropriate information to their parents and carers before the child age and prevalence increases.

This next graph shows the overall trend in the rates of overweight and obesity. We can see in general that overweight and obesity rates have been stabilising since about 2015. This overall would seem like a promising outcome, however it is not the case for all groups and we are seeing increases in some more disadvantaged groups as we will see on the next slide.

This slide highlights that the social disparities in prevalence are widening. Those from the lower socioeconomic status backgrounds are more likely to be affected by overweight and obesity and the gap is growing. The gap is widening. We can have, if you have a look on the graph, you can see on the bottom line that is for the highest socioeconomic status and they are sitting at around 19% and the rate of overweight and obesity has stabilised. The top line in blue highlights the group patients from the lower socioeconomic groups and their rates of obesity is rising and it has risen up to 33.7%. This is really important as it indicates that perhaps public health policy as well as being effective in higher socioeconomic groups, is not having enough impact on some of our socially disadvantaged groups and we need to start addressing those obesogenic factors in those more socially disadvantaged groups. And data from other countries is also supporting these findings.

Okay, so let us now have a closer look at some of the variation for children and adolescents above a healthy weight in socioeconomic groups and geographical regions. The children living in regional and remote areas are more likely to be above a healthy weight than those in major cities as you can see here highlighted in red. The reasons for this health differential may include the geographical location, socioeconomic disadvantage, shortage of healthcare providers and allied health, lower levels of access to health services and greater exposure to injury risks and poorer health of Aboriginal people who comprise a significant proportion of the population in rural and remote areas. We can also see on this graph that the prevalence of overweight and obesity amongst children and adolescents varies according to their socioeconomic status, with children in the lower socioeconomic groups more likely to be overweight or obese. For girls specifically, we can see here in the lowest socioeconomic groups, prevalence is as high as 38% compared with 24% of those in the highest socioeconomic group. This suggests that to achieve health equity, we need to think more about how we are addressing the health needs of these groups and the obesogenic factors that they face to improve prevalence rates for these groups.

The next slide shows the prevalence of overweight and obesity rates amongst Aboriginal children. Aboriginal children and Torres Strait Islander children as we have already seen have significantly higher prevalence of obesity than non-Aboriginal children in Australia. Complex issues contribute to the higher prevalence. We know in New South Wales, factors like unemployment, education, incomes, multi-household families and whether or not you rent or own your house, may have implications in the rates of childhood health and overweight and obesity. We also know that Aboriginal people may have a lower engagement with public health prevention initiatives and it is important that we start addressing these issues by increasing engagement by providing more culturally appropriate resources and programs and engaging Aboriginal health workers to help deliver these messages.

So this next slide looks at our CALD groups, culturally and linguistically diverse groups. As you can see on the graph here, if you are from an overseas background but born in Australia, the rate of childhood overweight and obesity is 27.7%, but it rises by 8% if you were born overseas. The most recent SPANS data supports this and we can see that in Middle Eastern backgrounds that it is much higher, specifically up to 42% and for boys from this population it is up to 48%.

So, how many families in New South Wales speak languages other than English? The census data from 2016 shows that in New South Wales, there are a large number of families where households speak languages other than English. The five highest ranking CALD population groups in New South Wales by language from the 2016 census data, were Arabic, Mandarin, Cantonese, Vietnamese and Greek. The top five countries of birth in New South Wales from non-English speaking countries are China, India, Vietnam, Philippines and Lebanon. And this again highlights the need to ensure that patients and families have access to appropriately translated resources and that a lot of these can be found on prohealth’s professionals website and we will talk about that more later in the talk.

So, these slides really start to look at the data in more detail and it is very interesting to have a look at the breakdown of data here. This is from the SPANS report, which is the Schools and Physical Activity and Nutrition Survey. And this is encompassing all school aged children aged five to 16 years of age. The SPANS report breaks down a number of health behaviours, and unsurprisingly children that were above a healthy weight are more likely to be carrying out behaviours that are putting them at risk. As you can see in the red, there are a number of health behaviours which characterise children well above a healthy weight. We can see across all BMI categories, things like vegetable intake is very low. We can see that children who are well above a healthy weight less commonly eat breakfast daily, they are more likely to drink more soft drink, for example at least one or more cups of soft drink per day. In children who are overweight and obese, the rate is 12% compared to those with a healthy weight, it is only about 5%. Looking at physical activity, children that managed to get into the healthy fitness zone ranged at about 73% in those of a healthy weight status, but it halved to about 44% in those who are overweight and about 21% in those who are well above a healthy weight or obese category. The amount of children reaching the recommendation levels of physical activity was only about 25% in the healthy rate, but it falls to 16% in those well above a healthy weight. Across all the groups we can see trends like high levels of sedentary behaviour such as car travel to school and high levels of screen time. We can also see at least 20% of children were eating take away foods at least more than once a week and it was increasing up to about 30% in children who were well above a healthy weight. When compared this to the 2010 data, there were some improvements across things like vegetable intake, screen time and take away in take overall, but in general we have still got a lot more work to do.

This next slide breaks down the data even further into locality, socioeconomic status, cultural background. We can see that children from lower socioeconomic and Middle Eastern backgrounds were less likely to eat breakfast. They were more likely to drink greater than one cup of soft drink daily. They were more likely to eat fast food and take away and less likely to be in a healthy fitness zone and meet daily screen time requirements. Children from an Asian background were found to be less likely to eat fruit on a daily basis, less likely to eat a healthy breakfast. They were found to be the least physically active group, but they were managing to get good amounts of sleep and reducing screen time. Overall, we can see that there are more behaviours linked to overweight and obesity rates in the children from lower socioeconomic groups and those from Middle Eastern backgrounds. We can also see the higher prevalence of children with childhood obesity and overweight in these groups.

Just to summarise, children from outer regional and remote locations are more likely to be above a healthy weight. Children from the lowest socioeconomic status groups are more likely to be above a healthy weight, and Aboriginal and Torres Strait Islander children have a significantly higher prevalence of obesity than non-Aboriginal children. Just a few things to think about in practice, how can we help families prioritise health behaviours when there are other factors in play such as being able to afford groceries or pay bills. We need to start looking at it from the perspective of how can we help families access those services and programs that they need when they are already faced with other more urgent issues on a daily basis. And policies and programs need to be in place and that is where the Premier’s Priority is trying to address some of these social determinants of health.

So these are some cultural considerations to think about in practice as well. We know that obesity is more likely to be culturally acceptable among children and teens from Middle Eastern and Pacific Islander backgrounds. We know that behaviours such as skipping breakfast, drinking too much soft drink or being rewarded with sweets is also common. We know that low levels of physical activity are common and fast food intake is higher. There are lots of barriers for migrant communities and this was identified by CALD parents in the study, you can see there the Cyril study in 2017. These barriers included things like post-migration priorities like parental responsibilities, time factors due to work commitments, employment and housing, finances, lack of transport, you know access to a car and difficulty catching public transport, lack of family support, were all listed as big factors that were affecting participation. Things like language barriers, their apprehension of joining groups when you were not from an English speaking background, previous traditional dietary practices, cultural perceptions of food and weight and cultural norms making difficulty to enact change were also listed as common. Health literacy was also an important factor, having people report that they did not have enough knowledge of food labelling in Australia and an ability to understand the information that was being presented and the lack of culturally appropriate and language appropriate information was lacking. Environmental factors such as living in areas where there are a high proportion of take away outlets versus fresh foods, advertising targeting children and peer and social pressures were also listed as important factors. They also listed policy barriers such as difficulty navigating our health system and fragmentation of our health programs. The enablers were listed as bicultural play groups, school liaisons and initiatives and community groups that were enabling and supporting patients to make changes.

This data is really interesting and a really big consideration that we take into place when we are talking to families and parents about a healthy weight or if their child is above a healthy weight. This data comes from the SPANS report 2015 and it shows that parents of children in years K to 2 and 4 were asked whether they considered their child to be very underweight, slightly underweight, about the right weight, slightly overweight or very overweight. And parents’ responses were examined against their child’s actual BMI. The first thing we could see, was that in about 85% parents of children who were in the healthy weight range were able to correctly see their child to be about the right weight. Those who did not perceive their child to be about the right weight, actually thought their child was slightly underweight, at about 13%. The second interesting point to see was that in children that were above a healthy weight, 73% of parents of children above a healthy weight perceived their child to be about the right weight, which really highlights for us in practice how we can approach this topic with parents, as not all parents are perceiving a problem. And finally, almost a third of parents well above a healthy weight perceived their child to be about the right weight. And just 60% of parents felt their child was only slightly overweight. Again this poses a challenge for us when raising the issue. It also highlights the need for the role of the health professional as educating parents. It shows that parents will need assistance when trying to perceive if their child is above a healthy weight, and otherwise the child may miss out on the appropriate interventions.

Okay, so now that we have had a look at and hopefully are understanding some of the issues parents and families are facing, let us see what we can actually do in practice. This is looking at using the four A’s approach which is highlighted on the healthy kids for professionals website. It is a new resource to support GPs and hopefully some of us are already familiar with it. Supporting GPs and health professionals to raise the issue of overweight and obesity with parents, it follows the four A’s approach of Assess, Advise, Assist and Arrange. On this website you can find a variety of resources including the BMI for age and gender charts, fact sheets for families and parents, weight status calculators and there is also an online learning module. It is free access for everybody and it also contains multilingual fact sheets and many translated resources.

So the first thing we want to do is assess the impact, and then we will move on to some cases. Just to re-summarise, children from a lower socioeconomic background, culturally and linguistically diverse backgrounds, face challenges across a number of areas, including less financial means or resources, for example to eat healthy, to exercise or seek medical intervention, especially if you are in a lower socioeconomic background. They may face barriers to access such as regional and rural areas and experiencing vast distances to services, language barriers and cultural perceptions of the health system are all complex issues. Families may have limited understanding of diet and nutrition, especially when moving from a traditional to a Western diet, and we need to know how we can help manage this in practice. And finally, environmental factors such as family, culture and home environment, the convenience of modern technology, fast foods and other contributing issues such as mental health and other health issues, as well as looking at the built environment. Does the suburb have any ability to walk to fresh food or are people relying constantly on cars and things like that to access?

Sammi: Before we move on to the case studies Natalie, there has been a couple of questions that have come through, so there is one asking about why we continue to use the diagnostic descriptor “obesity”. I think the Pro healthy kids website that you have just spoken about and the percentiles that we went over earlier, we are really being encouraged now to use “above a healthy weight” instead of that. Is that correct?

Natalie: Yes, that is right. Through all the research that has been conducted, the language has been changed to language that parents feel more acceptable. We know that the terms “obesity” when used with families has quite a negative connotation and it is often perceived as quite judgemental, so using the terms “under a healthy weight”, “well above a healthy weight” or a “healthy weight”, is you know, the most appropriate way we can start speaking to families about these issues. And it has been studies with families and children, that they find this language acceptable, easy to understand and yes, going forward these are the types of terminology that we should be using.

Sammi: Fantastic. And we had another question come through. Do we know anything about genetic factors that play a part in above a healthy weight in children?

Natalie: We have, through the research we have mostly seen that it is environmental factors that affect children’s weight, such as their intake of soft drinks, fast foods, whether or not they are meeting their physical activity requirements. So that in the most important things that we can really focus on when trying to deliver appropriate health care to patients from all backgrounds and all families.

Sammi: Fantastic. Let us move on to some case studies then.

Jessica: Thanks Natalie for going through all the statistics and setting the scene for the second half of the webinar where we will go through two case studies. And so these two case study subjects have had their name changed. They are real life case patients. So, we would like to make this half of the webinar as interactive as we can. So feel free to type in your questions and we will endeavour as much as possible to bring them up and go through them as well as keep to the time limit.

So, we will just start with Isaac here. Isaac is an energetic four year and four month old boy who comes to the practice for the first time. He is accompanied by his grandmother, Celia. She tells you she wants to get his immunisations up to date as he and his two older brothers have just come into her care from their mother due to issues of neglect. Celia would like Isaac to have his four-year-old immunisation as she has a letter from Centrelink stating he is not up to date with his childhood immunisations, and she is worried he will not be able to attend preschool without them. Whilst talking to Celia, is noted that Isaac may be above a healthy weight. What else would you like to find out at this point? If anyone has any comments, please send them through.

Natalie: So, I think whilst we are just waiting to see if anyone has got any comments or questions to start with, I think the most important thing is that we should try and find out at this point as we have just met Celia and Isaac, is are there any other factors going on. Is there carer stress for grandma? Is there you know, financial stressors or other competing priorities? Maybe as we have seen that missed childhood vaccinations is a common reason for children to present to general practice, but you know, it is a really vital and important role that we use this opportunity to conduct a more comprehensive health check at this time and find out a bit more about Isaacs developmental health and how he has been going overall. So I think the next thing we would like to find out is a bit more in his background history, birth history and how he has been going to date to find out if there are any more issues we need to discuss with Celia before just giving his vaccinations.

Sammi: Yes, and we have had some great responses come through asking that question about what can we see arising from this case, so we have got people asking about family background, diet review, socioeconomic status, does Celia think that Isaac’s weight is a problem, birth history and milestones. There is lots of stuff coming through there, so that is great.

Jessica: In terms of past medical history, he was a term baby born by a C-section. Mum’s pregnancy was complicated by maternal hypertension. His birth weight was 400… 4,000 grams, I beg your pardon, 88th percentile. He had a short admission to NICU for transient tachypnoea of the newborn. He was mostly bottle fed and started solids around six months of age. Celia reports he has a history of intermittent asthma, often triggered by viral infections, recurrent otitis media and he is a loud snorer. She is also worried about some of his development. She tells you, Isaac finds it hard to sit still and gets easily frustrated with other kids and has a limited vocabulary compared to his brother at the same age. He has a suspected peanut allergy, but no formal testing. And medications include Salbutamol two puffs as needed. Already we can see there are multiple issues in this child’s initial presentation. What are some of the issues we can see here?

Sammi: So if you can send us through via your chat box, let us know what you can see some of the issues might be in this initial presentation. Sleep apnoea, obese, steroids.

Natalie: So everyone is making some really good comments so far and I think, yes, picking up on some important issues here. So we can already see from the history that he had a large birth weight, so that is placing him at risk of other health issues later in life. There was risk of respiratory illness. He was in NICU for TTN. He was bottle fed, so there may be issues there. We also can see that he has got asthma, so we probably need to start thinking about is his asthma well controlled or not and do we need to check things like inhaler technique, does he have an action plan for example. Grandma has also mentioned some symptoms suggestive of obstructive sleep apnoea, and as people have mentioned in the comments, and we will need to start looking into an assessment for that. As well as that, Grandma has mentioned some issues regarding developmental concerns such as possible language and speech delay. She has reported he is suffering from recurrent ear infections and possibly there is effusion. Maybe he needs hearing testing, vision testing and maybe referral to the ear, nose and throat specialist and at some stage a paediatrician. We probably also need to think of some of the psycho, psychological and psychosocial issues. If there has been some trauma in the family, that would be really important in looking into Isaac’s development. Already, we can see that this case is going to be much more complicated and complex and have much more for us to deal with than just administering his childhood vaccinations.

Jessica: Moving on to the family history. There is type 2 diabetes, that Celia has been diagnosed with, hypertension for mum, asthma and eczema of his brother. In terms of social history, and someone has asked his ethnic background initially, Isaac is of Cook Islander background born in Australia. Parents separated and lives with his grandmother and two elder brothers. Mother visits regularly but grandma looks after his care. He goes to playgroup once a week. So at this point, we would just like to ask our audience, what issues could there be arising from his social setting that could potentially increase his risk for childhood – I was going to use the word “obesity” but now I have just stopped myself and I am going to say above a healthy weight, posing a challenge for management as well.

Natalie: And that is true, a term that we are used to using in the past and it is something that as health professionals, we should get used to using the new language as much as possible, especially when dealing with parents and families.

So, people are putting through some really good comments so far which is great. I think that some things that we would just like to think about in this case, is that we know now that he is from a Pacific Islander background and a CALD background and he may be at a raised risk of being at above a healthy weight. We know from the suburbs that he lives in that they are living in an area that is of a lower socioeconomic status and a high area of – high proportion of fast food outlets to fresh food. For example, in Western Sydney take away outlets have outnumbered fresh food in about a three to one ratio in about 28% of neighbourhoods, and that is from a study for Wollongong University. We can see from his family history as people are pointing out, that he might be at risk of metabolic syndrome and type 2 diabetes and we need to have a look at things like asthma, eczema and all of those factors. We should also take into account that if grandma is his main carer, she probably has her own health issues to deal with. She might be having stress relating to managing her own chronic and complex conditions, and we need to find out, does she have any extra you know, motivational support to help with Isaac’s potential health issues that we are starting to see come to light. And you know, if she does not have enough support for this, we need to find out who could help. Is it other family members available or can we look more widely into their LHD, for example there might be child and family nurse support available for her. We noticed that they mentioned that he only goes to playgroup once a week as a pre-schooler that might not be, you know, what is he doing on the other four days of the week? We think he might not be meeting his physical activity daily requirement of at least an hour per day of moderate to vigorous activity and we should enquire a bit more about what he is doing on those days when he is not at playgroup. And as we saw in the SPANS report data, there was a very interesting point, that a lot of parents did not actually know what the recommended daily activity, physical activity rate was, so about half of parents did not know that 60 minutes was required for most children.

Okay, so, so following the four A’s approach we want to look, this is based on the pro healthy kids website and we want to start with assessing Isaac a little bit more. So firstly, his examination findings. He is alert, well, running around the office. His heart and chest were all normal but he had bilateral dull tympanic membranes and his throat showed enlarged tonsils bilaterally. As part of a routine examination, we weighed and measured and found that his height was 120 cm, his weight was 32 kg and the calculated BMI was 22.2. So based on this information, we now want to find out what does that BMI mean, because we know that BMI changes, whether or not you are in an above a healthy weight or a healthy weight is related to your age. So we need to then have a look at the BMI for age charts. So these are the BMI for age charts for boys and girls which can be found on the pro healthy kids New South Wales website. They are easily – they have been designed to be easy to read. They are colour-coded to help display the information to parents and families and especially to those with maybe lower health literacy and maybe English is not their first language. Again, it uses the language of “below a healthy weight” for less than the 5th percentile, “healthy weight” 5th to the 85th percentile, “above a healthy weight” 85th to 95th percentile and “well above a healthy weight” which is the 95th percentile and above. So we should try and use these resources as much as possible in practice and they are all available on the pro healthy kids New South Wales website.

So as we go on. So we continue our assessment. So as you can see on the chart, we have plotted Isaac’s BMI of 22.2 and it places him well above a healthy weight for his age as you can see with the arrow there in red. So we think, well we better discuss this further with Celia, as it is part of our role as GPs to try and discuss how being above a healthy weight will have implications for a child’s health later in life and we want to you know, try and help families and carers understand this. Most important is to note that we do not want to just rely on a single measurement in time. We would like to be able to measure children routinely as part of regular clinical practice and start to assess the trends of their growth and that is going to be the most important factor to understanding how they are going and how they are progressing.

So, the next thing to do is, we will try and start a sensitive discussion about Isaac’s weight status being above a healthy weight. If anyone from their practice or from how they work has any comments or suggestions regarding how we could approach this, please feel free to send them through at this time, because everybody would have a different way of going about this. And there are many ways we could initiate this discussion. One possible way that we thought of, was that we could offer the BMI chart to Isaac’s grandma, so that she could see visually where Isaac was placing as above a healthy weight category. We want to explain to grandma that we have assessed his weight and we have found that his BMI calculated shows that his weight is in the range of well above a healthy weight. We want to ask her, does she have any thoughts about this? What does she think about it? Does the information surprise you or was she aware that there was a problem in this area? And definitely giving her time is very important and finding the amount of time to discuss it further, you know today’s visit might not be the appropriate time but we would like to offer her more time to discuss this issue as being above a healthy weight is likely to have implications for Isaac’s health in the future and we want to explain to her that it is our role as GPs to try and raise the issue with family members so that we can all work together as a team to help Isaac get back into the healthy weight range and help him to grow up healthy and happy.

So the next thing is we would like, is we would like to try and work on building an ongoing relationship with the family so that we can start prioritising these complex issues and following up as appropriate, and I think that some of the comments that have come through, to you know, give patients lots of good follow up appointments, to give them time to process the information and to follow up and find out the trends. So over the next few consultations which we arranged, we were able to discuss that children above a healthy weight can develop other health problems in childhood such as asthma, sleep disorders, hip, knee and ankle problems and things like high cholesterol and high blood pressure or metabolic syndrome. We also know from the data that children who are above a healthy weight are also more likely to become overweight as adults, putting them at risk of health problems like heart disease, diabetes and cancers. So when we had appropriate time for follow up, we were able to discuss with Celia that she was able to do a lot to help the family to develop healthier eating habits and keep them active and keep the whole family active and well. We were able to advise that they are not on their own to do this and we are here as a team to help make changes, to help Isaac get back into the healthy weight range for his growth and also to advise that children’s growth can change over time so it is important that we keep following up, keep reviewing his height and weight regularly and to monitor the trends, not to use one measurement in isolation. We also wanted to point out to her and discuss with her that there are plenty of options to help improve Isaac’s health, but the first and the best thing to do is to start off with things that you can do together as a family and that is definitely a more way of changing if the change is family-wide.

Jessica: Natalie, we just have a good question that has come up, and so someone in the audience asked, do we use these charts for all the children regardless of their race, birth place et cetera? I thought that would be a good one.

Natalie: Oh, yes, so that is a very good question. So, these BMI for age charts are developed from the CDC. The CDC BMI for age charts, and when they develop these charts they used data from children from all backgrounds and ethnic backgrounds and they found that the overall rate of growth can be expected to be the same for children no matter what kind of ethnic background they came from and that the most important factors were things like the environmental factors like diet, exercise and sedentary lifestyle and things like that. So yes, we can use these charts across all children. They have been established for that reason.

So, the next thing we want to do following the four A’s approach is to help assist. This is using the 8 for healthy weight chart, and hopefully everyone has seen this already, but if not we will go through it. So, after we have gone through the process of assessing Isaac’s weight for age and advising his grandma Celia that he is well above a healthy weight, she wants to know what can she help to do to improve Isaac’s growth to make him more healthy. So, we said well this is a very simple and straightforward way that you know, she can help the whole family develop healthier eating habits and keep them active and well. So this is the 8 for a healthy weight chart and it has eight simple strategies that families can do together to help improve the whole health of the whole family. Things like, drinking water instead of juice, cordials or soft drinks. Increasing vegetables to at least five serves a day and two serves of fruit per day. Trying to start the day each day with a healthy breakfast. Knowing portion sizes and serving sizes that is really, and sticking to those sizes. Changing the snacks from more treat foods to more healthier snack food options. Limiting screen time to the recommended times per day and increasing physical activity up to at least an hour a day for all kids. Most importantly, getting enough sleep as all kids need the appropriate amount of sleep. And most in the middle it shows to do it all together as a family. The main thing I think to try here is to try and use some motivational interviewing techniques to find out what you know, Celia or a family member thinks that they can actually do. What is going to be realistic for their family and what do they think is achievable? And then I think we will start to get some success. And also on the pro healthy kids website, this is available in multiple translations, for example Arabic, Vietnamese and many other languages. So you just need to go to pro healthy kids to find that.

Okay, so after making sure that Isaac’s four year old vaccinations were up to date and completed which was his presenting issue, we continue with our follow up visits with Celia and Isaac to see how they are going with some of the simple changes based upon the 8 for a healthy weight guidelines. We want to try and provide as much support as possible at this stage so the family feels supported. So regular follow up visits will help. We also note that there are other, as we have discussed throughout the case so far, that there are other health issues that we will need more time to assess, such as his asthma control, symptoms such as his snoring and is it linked to sleep apnoea and his grandmother Celia’s concerns about his behaviour and development. So, I think getting the appropriate follow up is important and it is important to note just finally for this case, that whilst children who are above a healthy weight tend to have more complex health conditions, the studies have shown that there is a direct health care cost for children with obesity, or being above a healthy weight, aged two to four years were 1.6 times more likely to spend more on health, to need more spent on their health. So, they were, there is a direct link between being above a healthy weight and those other health conditions. We just put on the slide there, you know, we could also use the Get Healthy service to support the carers and Celia in this case, and using your medical program recall system to try and be systematic in the approach of following up the family is important and to try and engage the whole care team. And that may be different depending on your setting. You might have practice nurse or Allied Health or community child and family nurses, but to try and make the family feel as supported as possible is really important.

Jessica: Thanks for your questions that are coming in. So we have a few questions about nutritional guidelines and we will go into them a little bit later as we proceed into our next case study. And this case study is about an eight year old boy called Danny who is known to the practice, brought in by his grandfather with an ankle pain. Danny was playing at lunch when he rolled his ankle. It was instantly painful and difficult for him to walk on and is now a bit swollen. His grandfather, who always picks him up after school and looks after him until his mum gets home is worried it might be fractured. His medical history is significant for recurrent impetigo and frequent episodic asthma. Lots of asthma in the country right now. Allergic rhinitis. Immunisations are up to date. Medications include Flixotide twice a day, Ventolin Q. 4 hourly and Nasonex Junior. No known allergies. What issues might be important at this stage?

Natalie: So if anyone has got any thoughts, please send them through. But some things we can already see from this case is that being above a healthy weight may be associated with things like poorly controlled asthma, musculoskeletal conditions and also there might be some social factors in this family setting as well. Again, Danny is mostly in the care of granddad. Parents might be working long hours, so we need to find out a bit more about what is his routine like at home? Is he meeting physical activity levels and how is his dietary intake looking?

Jessica: In terms of his family history, maternal grandmother has type 2 diabetes, sister has asthma and eczema. Social history. Parents were born in Australia from an Egyptian background. His parents have recently divorced and his mum has remarried. The new partner is of Samoan background. He has one elder sister. His maternal grandfather provides the majority of his after school care while his mum works and grandfather attends medical appointments. He attends year 2 at a local primary school.

Natalie: And again, just issues to note here. He is of a background where we already have seen from the data that he is at risk of being more above a healthy weight. Multiple languages are spoken at home and there are family risk factors for things like type 2 diabetes as well as psychological and psychosocial stressors such as he has witnessed his parental breakup. You know, he might be having mental health issues as well. And we want to also find a little bit more… a little bit more history.

Jessica: Danny’s grandfather asked if you can check Danny’s growth as he is worried that he is above healthy weight and asked if his ankle injury could be related to his weight. Danny has also reported being teased at school about his size. He eats a healthy snack with grandfather in the afternoons after school, but when mum and step dad get home late from work they often get a take away for dinner, for example chicken and chips three times a week and they have a can of soft drink with dinner. He is also not meeting his daily requirements for physical activity. He does not like sport and prefers to read or play video games. Grandfather is worried about his self-esteem as well as effects his weight may have on his future health.

Natalie: And again there are lots of issues here with high amounts of take away food, the intake being associated with being above a healthy weight which we saw in the SPANS data, not meeting vegetable intake and not getting enough physical activity a day. He is also having a high amount of processed food and that might all be factors for Danny.

So next, following the four A’s approach, we would like to assess him same as we did for Isaac. So we have got his height, weight and calculated BMI there. We also note as we examine him for his presenting issue, he has got an antalgic gait. He has got some left ankle swelling and he is tender over the lateral malleolus. But importantly, we do note that there are some signs of acanthosis nigricans on and around his neck.

Jessica: Just a question to the participants to get them thinking. Given the family history and examinations, what would you be concerned about right now? So we have people writing in, concerns about diabetes.

Natalie: That is right. Yes, there is a higher risk for insulin resistance pre-diabetes and metabolic syndrome. So we will go on to continue to assess how Danny is going. We are using the BMI for age charts from the pro healthy kids website, and again we have plotted his BMI for age and find that he is placed well above a healthy weight. So we want to advise, we want to maybe show granddad this chart and as his mum and dad and step dad are not there today, we suggest maybe he could take this home and bring the whole family in next time for a more detailed chat as well, after we have sorted out Danny’s ankle injury. So when we, granddad mentions that he is not sure that the rest of the family will be able to get involved due to their work commitments but he will do his best. We find out, we tell him that we would like to discuss Danny’s being above a healthy weight due to the implications it can have upon his health later in life. So hopefully he can get them to come back in, and when he does we will have a chat with what we can do to assist him further. So again, we can use the 8 for a healthy weight chart with Danny’s grandfather and his family and we were able to get his mum and step dad in for future visits. We were able to use this framework to make simple changes that the whole family could do together. In this case specifically, we tried to help see if the parents could provide a focus on providing more healthier snack food options and lunch box options and increase his fruit and vegetable intake. We also discussed how we could reduce take away foods to fit in with their busy schedule and with that try to reduce his soft drink intake. We tried to look at swaps, for example his lunch used to be a white bread sandwich with some kind of spread like a vegemite or jam. We discussed how could we change this to maybe wholemeal bread or salads or things like that. We also tried to educate about appropriate portion size and again arranging regular follow up within a month so they could come back and discuss this further. And the 8 for a healthy weight is a really useful framework for discussing what approach we can take with families, especially if they are in a lower socioeconomic area or rural and remote area where more health services are not available.

So again, we tried to arrange more follow up and we wanted the main goal to be to get the whole family involved in taking part and to keep following up until we got that family engagement. We considered referrals such as Go 4 Fun for Danny and the Get Healthy service which is providing advice and support for his parents and family, and in this case, we see that Danny has chronic asthma, so he would be eligible for a team care arrangement and a GP management plan, and so we were able to arrange this for him and provide referral to our dietician who was part of our care team, who then she could provide even more advice and follow up with the family.

Jessica: Oftentimes in my practice I have found that it is so helpful to work with a dietician to provide dietary advice for different kinds of chronic conditions including weight loss, diabetes and even chronic renal disease. They are really capable and skilled to provide really good advice, and we do know that in some communities, like outer regional communities, they might not be accessible to getting a dietician review and so we have come up with a few resources that could offer some brief dietary advice as well. So, the ones that we have found would be the Australian Dietary Guidelines available on the NHMARC website have great pictorials of serving sizes for each food group and also healthykids.NSW.gov.au has some great resources. And I know of another one just of the top of my head called RaisingChildren.net, also has really, really good nutritional advice and actually according to different age groups as well. So there are resources out there for all GPs who cannot seem to get their patients to see a dietician for whatever reason, whether it is affordability or because the resource is just not available, there will be some guidelines available for help.

Natalie: And lastly, we would just like to go into a little bit more about some things we have mentioned in the cases, so the Go 4 Fun service which is a free healthy lifestyle program for children in New South Wales aged 7 to 13 years who are above a healthy weight or are above the 85th percentile. Parents and carers do need to be available as they attend a parental session while the children spend a session with physical activity activities. They learn things about nutrition, appropriate physical activity, behavioural changes and family changes. It is all free and it is usually provided during term times. So it goes for about 10 weeks and is delivered by a dietician or exercise physiologist or other qualified health professionals. It has got a really great reach so far, over 1,000 programs have been run already across New South Wales reaching about 11,000 families. And the stats from the program show that there has been improvements in BMI by at least 0.5 kg BMI and waist circumference has reduced and they have also noted improvements in children’s activity levels and general nutrition levels and importantly it is free and can be accessed by families in lower socioeconomic areas. It also runs as an online program for those in rural and remote areas and there is an Aboriginal and Torres Strait Islander version for patients and families from Aboriginal and Torres Strait Islander background that has got Aboriginal support staff and traditional food games and resources.

Sammi: And we just had someone comment that the program is not available in North Tamworth, north of Tamworth sorry, so Go 4 Fun now has an online program as well. What I will do in the resources that we send out tomorrow, I will send you links to the Go 4 Fun webinar that we ran that outlined all of the services available both face to face and online.

Natalie: And just it is really important for GPs to make the referral. All the information about how to refer is here on the slide. If GPs refer, they will get feedback from the Go 4 Fun program which is really important in closing the loop for communication so that we know what has happened to our patients and families when we have sent them out into the program. It helps families take up the program if the GP refers, as like we said before, GPs are a trusted source, so parents and families are more likely to take up the referral if it is made through the GP or the practice nurse or someone else in your care team.

And finally, the Get Healthy service. It is an information and coaching service which is run over the phone. It is for everyone aged 16 and up and it provides coaching calls to help with patients to get motivation to make goals and to improve things like their physical activity, weight management. They can look at programs for reducing alcohol intake and there is also a program for gestational diabetes. It is a really useful service and again if GPs refer we will get a report back from the Get Healthy service for how your patient went. Just important to note, there are resources for patients from culturally, linguistically and diverse communities. There is the use of a translator and interpreter service and 20% of participants were from CALD backgrounds. They are also trialling a bilingual coaching model and a coaching model for Aboriginal participants using an Aboriginal liaison officer to try and make the program culturally appropriate for everybody.

Sammi: Alrighty, so this is just reviewing the learning outcomes that we went over at the beginning, so we hope that now that we have come to the end that you will go away being able to do these things. I would like to thank our presenters, Jessica and Natalie very much for joining us tonight. I hope everyone online enjoyed the session. Thank you again Natalie and Jessica for joining us and good night everybody.